Inspection on 19/02/07 for Whiteheather

This inspection was carried out on 19th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whiteheather 13/12/07

Whiteheather 14/02/06

Whiteheather 21/10/05

Whiteheather 17/11/04

Whiteheather 11/06/04

Whiteheather 29/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Whiteheather Clacton Road Weeley Essex CO16 9DN Lead Inspector Pauline Dean Key Unannounced Inspection 19th February 2007 09:15 Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteheather Address Clacton Road Weeley Essex CO16 9DN 01255 830502 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) White.heather@btinternet.com Whiteheather Care Ltd Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 5 persons) 14th February 2006 Date of last inspection Brief Description of the Service: Whiteheather is a detached bungalow offering care for five younger adults with learning disabilities. The property is situated on the Clacton Road, in the village of Weeley, Essex. Within the village there are local shops, a post office and schools. Public transport is available and the home has their own transport. This home was opened and registered in 2003 by the present proprietors, Whiteheather Care Ltd. Mr Gamika Rasal Gunasene is the Responsible Individual. The Registered Manager position is currently vacant. The property is set back off the road, with parking areas. At the rear of the property there is a large enclosed garden with decking and a BBQ area. There is a garden shed for storage. The front garden has an ‘in and out’ driveway with trees and lawn. Bedroom accommodation comprises of five single bedrooms, all with en-suite facilities of a toilet and wash hand basin. In addition there is a bathroom with bath, overhead shower, wash hand basin and toilet, there is also a separate shower room and separate toilet. Communal accommodation comprises of a lounge/dining room offering access to the back garden. The kitchen and laundry are comparable with those found in a normal household. Current fees are from £1,400 per week. These fees are negotiated and they will depend on staffing levels required, the service user’s dependency and the individual assessment. Hairdressing, toiletries and personal equipment are purchased at cost. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, covering the key National Minimum Standards, took into consideration all recent records relating to the service, including information sent to the Commission by the Providers. A record of inspection was collated prior and during the inspection process. It also included a site visit to the home on 19/02/07, which lasted approximately 9 hours. Miss Elizabeth El-schaeddhaei, the acting manager was present and two care staff were spoken with during the inspection. All three service users were met during this inspection. Mr Gamika Gunasene joint proprietor and Mr David Harden, Financial Director called into the home during the inspection. No visitors or relatives were present during this inspection. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of two service users, a process known as case tracking. Survey work completed by the Commission resulted in one comment card from a relative, two comment cards from health and social care professionals and three service users surveys completed with assistance by care workers. Their comments are reflected in this report. Of the twenty-five National Minimum Standards inspected on this occasion, eighteen were met, six nearly met and one nearly met which is highlighted as a recommendation. Whilst the last inspection report had only two requirements, it should be noted that only twelve standards were inspected on that occasion and the home has since had a change in management. What the service does well: Whiteheather has a detailed and comprehensive care plans and risk assessments in place. On taking over the management of the home, Miss Elschaeddhaei, the acting manager has reviewed and revised the paperwork held on each file. Additional record sheets have been added to give even greater depth to the record keeping. Staff recruitment was found to be well managed. Miss El-schaeddhaei was able to demonstrate a good understanding of recruitment procedures and induction processes. Both National Vocational Qualification (NVQ) training and basic core-training courses are promoted within the home. Miss El-schaeddhaei has a NVQ Assessor’s Award, which assists with this process. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation ensures that service users move into the home knowing that their needs will be met. EVIDENCE: Miss El-schaeddhaei, the acting manager of Whiteheather, has reviewed and updated both the Statement of Purpose and the Service Users’ Guide. Whilst these are detailed documents, clarification is required as to the number of bedrooms. In the Service Users’ Guide there is inconsistency for it is stated there are five bedrooms and also there are six bedrooms. In addition the Service Users’ Guide states ‘Whiteheather will be registered as a Residential Home’, when it has in fact been registered since 2003. The acting manager is advised to review these documents to ensure that prospective service users and their placing authorities have accurate information they require to make an informed decision on admission to the care home. There have been no new admissions since the last inspection. The most recent admission was in 2004. This was before Miss El-schaeddhaei took on the role of acting manager at Whiteheather. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 9 Records found on the service users’ file however detailed a comprehensive assessment process completed by the former registered manager and the placing authority. Miss El-schaeddhaei had a good understanding of the process. She spoke of the need to arrange visits with the prospective service user’s care manager and relative prior to admission and gradually increase the length of these visits offering both overnight and weekend stays. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning documents detailed health, personal and social care needs and records evidenced all aspects of care required. Service users are enabled to make decisions through risk assessments and risk management. EVIDENCE: Care plans have been developed for all three service users. Approximately fifty care plan needs are considered and these goals covered all aspects of personal and social support and healthcare needs as identified from their initial assessments. Within these documents there was evidence of staff management strategies and intervention and the records clearly detailed who is responsible for what action. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 11 Two care plans were sampled in detail at the site visit. Since taking on the management of the home Miss El-schaeddhaei has reviewed and revised the care planning files dividing the files into two, one hold correspondence etc. and the second holding the current care plan. Care plan needs are monitored and reviewed at six monthly intervals or more frequently as required. Miss El-schaeddhaei said that she has introduced key workers into creating and managing care plans. Monthly key worker reports were seen on file and these referenced care planning needs and goals and all other records. For one service user there was evidence of a smoking management plan, which was linked to a care plan need. This had evidence of planned management strategy with review dates set and planned. Alongside this there was evidence of a risk assessment and management tool, which covered all aspects of risk to self, health and property. Further general risk assessment forms highlighting risks, triggers and factors and a management plan had been created as required and were found on both service users’ files. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff support and assist service users to participate in educational, training and community activities, as they are able. Staff support service users to maintain family links & friendships. Service users rights are respected and responsibilities are recognised. EVIDENCE: Improved record keeping has provided evidence of tasks and activities completed by individual service users. This record keeping had enabled care staff to focus on activities and tasks which had been undertaken by service users. It was seen from these records that there was a concentration of solitary household tasks. For all three service users there are limited external Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 13 opportunities offered to them. One service user was attending a college course – Touchy/feely course. This was discussed with Miss El-schaeddhaei. It is acknowledged, that the present resident group do offer very challenging behaviours and therefore these opportunities are limited. However, it is recognised that this area of care does need to be developed. Planned individual programmes were on display in the office. These however, did not give an accurate record of activities offered, for some changes were evident from records seen and activities on offer on the day of the site visit. At the site visit service user survey forms were left with the home and all three service users had responded. All had required assistance to complete these forms. Within these forms two of the service users had said that sometimes they are able to make decisions about what they wanted to do each day and one service user said that they were always able to make such decisions. They had commented, “I tell the staff what I want to do and refuse what I don’t want to do.” From discussion with Miss El-schaeddhaei and records seen it was evident that the three service users may attend the Gateway Club as they wish. Mini-bus rides in the community were also popular and this was demonstrated on the day of the site visit. Only one service user has links with their family. They have weekly visits from their family and are able to see them in private in their room or in the communal areas of the home. Miss El-schaeddhaei said that service users’ rights and responsibilities are respected and recognised. An example was the opening of mail. Records detailed how this was managed for individual service users. During the site visit, service users were seen to come and go from their bedroom as they wished and they were able to choose whether they wished to go for a mini-bus ride, when one of the service users was taken to a college course. Further evidence of choice was seen in the nutrition records held for each service user. Records are kept of choices made by each individual service user. A four-week rotation menu has been planned for the months of January 2007 – July 2007. Individual nutrition records identified the choices made by each individual service user. A variety of meals are served at breakfast, lunch and dinner time. Shopping is undertaken three times a week, by the homes own ‘shopper.’ Ample storage is available in the two fridges and two freezers in the home. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 14 The latter are found in a garden shed, which also houses cleaning materials and some dry goods. During the site visit, the inspector noted the care staff response to offering drinks and snacks between meals to service users. This was handled very well, with drinks offered as appropriate and explanations given when it was not appropriate e.g. a service user requests a cup of tea having just finished one. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for supporting the healthcare of service users was well managed. Medication administration and dispensing had major shortfalls, which failed to protect service users. EVIDENCE: During the site visit, there was evidence of staff providing individual personal support for the service users. Technical aids such as a raised toilet seat, plastic cutlery and a harness belt for travelling in the mini-bus have been introduced for individual service users. These were all documented in their care plans and their management was reviewed through this document. As stated earlier in this report, service users are encouraged to make decisions. One service user was able to choose whether they wanted a bath or a shower and they were able to select their clothing. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 16 All three service users attend one GP practice. Miss El-schaeddhaei said that appointments are made with the surgery and service users are escorted to the surgery. Six monthly reviews of medication and behavioural reviews are completed by the psychiatrist and the Community Nurse team and appropriate referrals are made as are needed. Survey work completed by Commission for Social Care Inspection (CSCI) resulted in two responses from healthcare professionals. These were from a Community Nurse and a Consultant Psychiatrist. There were positive responses to the questions in this survey. One commented “carers are proficient in managing and minimising risks in the most appropriate and acceptable ways.” Medication administration, storage and record keeping was sampled and inspected for all three service users in the home. Boots the Chemist Monitored Dosage System is used in the home. Record keeping and administration was reviewed and inspected and a number of shortfalls were found. • • • • • • Both the top copy and the carbon-copy MAR sheets were held together in the medication folder A MAR sheet detailed that a service user had received a tablet for the evening of the site visit, earlier than required. Caneston cream was found in current medication for dispensing, but there was no record of this medication found on any of the MAR sheets. Medication had been signed in, whereas the MAR sheet stated that none had been received. One service user had an abundance of a scalp solution in the medicine cupboard, some dating back to June 2006. During the site visit medication was seen to be decanted, MAR sheets signed and then the medication taken to be administered to the service user. All of these concerns were raised with Miss El-schaeddhaei who acknowledged the shortfalls. Following the site visit a thorough overall of medication administration practices has been completed by Miss El-schaeddhaei and prior to writing this report, a detailed report of the review undertaken has been given to the Commission for Social Care Inspection (CSCI). Miss El-schaeddhaei said that she had raised these issues with all staff at Whiteheather through supervision, handover/staff meetings and the detailed report. She had taken over the responsibility for overseeing medication administration in the home and was pursuing both basic and advanced medication training for all staff. She was advised to ensure that all medication training is accredited and it should Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 17 include basic knowledge of how medicines are used and how to recognise and deal with problems in use. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, service users were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Whiteheather has a concise complaints procedure. This was reviewed and inspected at the site visit and some amendments and revision was required. Miss El-schaeddhaei revised this document and a copy was given to the Commission for Social Care Inspection (CSCI) prior to writing this report. This was found to meet requirements. An adult protection policy was seen to be in place. This document reflected local authority guidance and made reference to the Protection of Vulnerable Adults (POVA) register and Protection of Vulnerable Adults (POVA) 1st Check. Miss El-schaeddhaei spoke of using these checks when recruiting new staff. Adult protection training is currently being pursued using the Essex County Council DVD on adult protection. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the home provides a safe, well-maintained environment that is accessible to service users, homely and meets individual needs. EVIDENCE: A tour of the premises was undertaken at the site visit. Whilst not all of the bedrooms were seen, the inspector viewed the three occupied rooms. These were sparsely furnished with little evidence of the individual who occupied the room. Whilst it is recognised that these surroundings are brought about by the challenging behaviour of the individual service users, the need to personalise and create a more homely environment was discussed with Miss El-schaeddhaei. Issues around privacy and curtaining in the bedrooms were considered. The practice of using opaque film on bedroom windows needs to be reviewed and fully detailed in the service user’s care plan. Some attempts to hang pictures have been successful and Miss El-schaeddhaei agreed that further effort needs Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 20 to be made to create a homely environment especially in service users’ bedrooms. In contrast the newly extended lounge and dining room area was both comfortable and homely. The television had been housed in a fitted unit and sufficient sofas and easy chairs are to be found in this room. A dining room table and chairs are in place, offering ample places for all of the service users. Pictures, large potted plants and flowers in this communal area create a homely, bright room. Copies of the planning approval, Fire Officer recommendations and Certificate of Completion from Tendring District Council were not available at the site visit, but have been sent to the Commission for Social Care Inspection (CSCI) following this visit. Access to the rear enclosed garden is via patio doors to a large decking area and roofed picnic area with a garden table and benches. The smokers in the home can use this area. The garden is laid to lawn with some shrubs and trees. Each bedroom has an en-suite facility of a toilet and wash hand basin. Of those visited on the site visit the absence of a towel rail and it some cases a toilet roll holder was raised with Miss El-schaeddhaei. The main bathroom had a bath, overhead shower, and toilet and wash hand basin. Miss El-schaeddhaei said that the majority of the service users choose to you this bathroom, rather than the separate shower room. Whilst not presenting as a health hazard, attention is required to the sealant, which is discoloured and showing signs of fungi coloration. Whiteheather has a separate utility/laundry room. In this room there are two washers and one dryer. One of these machines was missing a time knob and whilst it was fully operational, repairs are required. Miss El-schaeddhaei said that service users are encouraged to take their laundry to the laundry room. This was seen in activity records inspected and confirmed by a member of the care staff. Ironing is completed as and when is needed during the day and night. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to keep service users safe and address their basic needs. The home has an experienced and dedicated staff team and service users are protected by the home’s recruitment practices, supervision and training. EVIDENCE: Miss El-schaeddhaei said that there have been some staff changes at Whiteheather since the last inspection. Miss El-schaeddhaei had been brought in as the acting manager and has made an application for registration as the registered manager. This is currently being processed. As a National Vocational Qualification (NVQ) Assessor she is currently reviewing the management and position regarding NVQ training in the home. Miss El-schaeddhaei said the home continues to promote both NVQ level 2 and 3 training in the home, alongside basic training courses. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 22 Positive comments had been received from the comment cards sent to health and social care professionals. One comment was – “From what I have observed the carers are proficient in managing and minimising risks in the most appropriate and acceptable ways.” Miss El-schaeddhaei said that she is trying to introduce female staff into the home. Whilst she recognises that the present service user group is all male, she feels that a feminine input alongside herself as the manager would be beneficial. Staff rotas were inspected at the site visit and throughout the day there were three care staff on duty, thus giving 1:1 support for service users. At night there was one awake and one asleep member of staff. The management of the manager’s hours was discussed with Miss El-schaeddhaei and she said that she allocates her time between the two homes. Staff rotas given to the inspector after the site visit, detail Miss El-schaeddhaei’s hours at each home. Staff files were sampled and inspected of two care workers. These records were well managed with evidence of a detailed application form, written references and Criminal Record Bureau (CRB) disclosures or Protection of Vulnerable Adults (POVA) 1st Check in place. Of those files inspected one was for a new member of staff. Evidence was seen that this new member of staff was working on Skills for Care Induction Course and they had started a NVQ level 2 in care course at their previous employment. At the site visit, the inspector was able to speak with this member of staff and they confirmed that they were newly appointed and were currently being closely supervised. They said that both management and staff were very supportive and should they have any concerns they would raise with the deputy manager of Miss El-schaeddhaei. They said that on completion of their Induction Training they are hoping to complete their NVQ level 2 in care. Whiteheather has an in-house basic training programme set up for 2007. Miss El-schaeddhaei said that five basic training courses are to be offered this year. They are Manual Handling (loads), Health & Safety, Infection Control, Food Hygiene and First Aid. In addition training courses on Epilepsy Awareness, Rectal Diazepam, Protection of Vulnerable Adults (POVA), Bowel Movement, Administration of Medicines, Breast Screening Awareness and Maketon. These courses are to be offered to all staff in the two care homes of Whiteheather and Four Winds. The management of supervisions and annual appraisals was considered with Miss El-schaeddhaei. The inspector saw copies of a detailed supervision session following the site visit. Participation in staff supervision is expected with both management and staff expected to contribute to these sessions. A planned and agreed agenda is used. Miss El-schaeddhaei stated that supervisions and appraisals are planned and programmed in the home’s diary. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 23 She said that she intends to use these sessions not only to supervise care practice and management of the home, but as an individual training session too. Additional supervision sessions however can be brought in as required. A recent supervision session record sheet detailing medication issues found on the site visit evidenced an example of this. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a qualified, competent and experienced manager to run the home. The home has a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the service users. Safe working practices are promoted through ongoing training. Health and safety certification promotes a safe working environment. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 25 EVIDENCE: Miss El-schaeddhaei has made an application for registration as the registered manager at Whiteheather. This is currently being progressed and an interview date has been arranged to discuss the management arrangements for Miss Elschaeddhaei to manage two homes. Miss El-schaeddhaei has completed by the NVQ level 4 in care and the Registered Manager’s Award (RMA). In addition she has gained an award as a NVQ Assessor. Whilst Miss El-schaeddhaei is new to the management of Whiteheather, she has been operating as the registered manager of the sister home from July 2005. Since taking on Whiteheather, deputy managers in both homes have taken on defined duties and responsibilities, as have key workers in each home. Miss El-schaeddhaei recognises the need for both delegation and overseeing the care management of the homes. A quality monitoring survey was completed in December 2006. Whilst this was limited as few relatives are involved in the care of the current service user group, feedback of this work has been added to the Service Users’ Guide. Miss El-schaeddhaei said that she plans to expand the quality assurance and quality monitoring processes. She said that she is going to produce a quarterly newsletter requesting feedback from care managers, GPs and other health and social care professionals. Regulation 26 visit reports are also seen as part of the quality assurance methods in the home. Copies of the visits made in June 2006, October 2006, December 2006 and January 2007 have been sent to the Commission for Social Care Inspection (CSCI) and these provided an insight into the current practice and management of the home at the time of the visits. Safe working practices in the home are promoted through training courses and ongoing supervision and management of the home. Reference to planned basic training courses is to be found earlier in this report and the management of supervisions and staff meetings are in place and they meet requirements. Safe working practices with regard to fire drills and fire safety training records were seen and following training in June 2006, training had been updated in January 2007. Miss El-schaeddhaei recognised the need to re-introduce this refresher training and drills at more regular intervals. Fire Alarm testing, emergency light testing and fire extinguisher testing had all been completed in January 2007. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, 5 Requirement Timescale for action 09/04/07 2. YA12 3. YA20 4. YA24 The registered person must review and update both the Statement of Purpose and the Service Users’ Guide to ensure that it is fully accurate. 16(2)(m) The registered person must ensure that staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 13(Schedule The registered person must 3), 17, 18 ensure that medication is held, stored and administered according to the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 16(2), The registered person must 23(2)(p) ensure that bedroom accommodation meet service users’ individual and collective needs in a comfortable and homely way. This is with particular regard to matters of privacy and window dressings in the bedrooms. 09/04/07 09/04/07 09/04/07 Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 28 5. YA30 13, 16 6. YA37 8, 9 The registered person must ensure that laundry facilities are in good repair and in good working order. The registered person must ensure that the service users benefit from a well run home by the appointment of a qualified, competent and experience registered manager. 09/04/07 09/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations The registered person should comply with statutory fire safety requirements and ensure all staff are fully aware of evacuation procedures in the home. Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Whiteheather DS0000048917.V330764.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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